Interested in Programs?

We know you’d do anything for your kids. Let’s make your job a little easier.

Parent/Guardian Name

Parent/Guardian Date of Birth

Phone Number

Email Address

Full Address

How do you prefer to be contacted?

Phone Call

Text Message

Primary language at home?

Child Name

Child Date of Birth

Do you have another child you would like to apply for services for?

Yes

Child Name

Child Date of Birth

Do you have another child you would like to apply for services for?

Yes

Child Name

Child Date of Birth

Do you have another child you would like to apply for services for?

Yes

Child Name

Child Date of Birth

What services are you interested in? (select all that apply)

Child Care

Preschool

Family Support

I don't know

Please rank the following Preschool options

Is there anything you would like to share about your child, family, or needs?

On the South Coast, enrollment priority is given to children experiencing the following

* Homelessness
* Foster Care
* Diagnosed disability or developmental delay
* Primary language other than English
* Black, Indigenous, and children of color
* Parent with a mental illness, substance use disorder, and/or serious health condition
* Experiencing/experienced trauma

Do any of these apply to your family?

Yes

By submitting this form, I understand and agree that the information on this form may be shared with entities and individuals involved in Baby Promise, Preschool Promise, Relief Nursery, and Head Start Programs, including preschool providers, Enrollment Committees, Early Learning Hubs, Education Service Districts, Child Care Resource and Referral, and the Oregon Department of Early Learning and Care. If you need help of any kind please contact our staff at 458-710-0902 or email enrollment@screlhub.com.

Signature

What programs are available?

Learn about available programs

Many programs are free or available at a reduced rate based on income.

Paper Form

Paper forms can be mailed to PO Box 237 Coos Bay, OR 97420

Program Interest Form

Formulario de interés

Questions about applying?

Please contact us.

Note: It may take up to 7 days for us to process your request. If your needs are urgent and non-medical, call 211. For urgent medical or infant feeding needs, reach out to your medical provider.

	1st Choice	2nd Choice	3rd Choice	Do not want
Head Start
Bandon Community Child Care Center
Bitty Bulldogs (North Bend Residents Only)
Little Pirates (Coos Bay Residents Only)
Any Preschool